Page 307 CHAPTER 13Paranoid symptoms and delusional disorders
Causes of paranoid symptoms 308
Paranoid symptoms 308
Paranoid personality disorder 309
Paranoid symptoms in psychiatric disorders 31 o
Delusional disorders (paranoid psychoses) 310
Classification of delusional disorder 312
Epidemiology of delusional disorder 313
Aetiology of delusional disorder 313
Specific delusional disorders 313
Pathological jealousy 314
Erotomania and erotic delusions 316
Somatic delusional disorder 317
Querulant delusions and reformist
Shared (induced) delusional disorder 318
Assessment of paranoid symptoms 318
Treatment of paranoid symptoms 319
General principles 319
Psychological treatment 319
Drug treatment 319
The term paranoid can be applied to symptoms, syndromes, or personality types. Paranoid symptoms are overvalued ideas or delusions which are most commonly persecutory but not always so (Box 1.2, p. 11). Paranoid syndromes are those in which paranoid delusions form a prominent part of a characteristic constellation of symptoms, such as pathological jealousy or erotomania. In paranoid personality disorder, there is excessive self-reference and undue sensitiveness to real or imaginary humiliations and rebuffs, often combined with selfimportance and combativeness. Thus the term paranoid is descriptive; if we recognize a symptom or syndrome as paranoid, this is not making a diagnosis, but it is a preliminary to doing so. In this respect it is like recognizing stupor or depersonalization.
Paranoid syndromes present considerable problems of classification and diagnosis. The difficulties can be reduced by dividing them into two distinct groups:
1. Paranoid symptoms occurring as part of another psychiatric disorder, such as schizophrenia, mood disorder, or an organic mental disorder.
2. Paranoid symptoms occurring without evidence for any underlying disorder. This group of disorders has gone by a variety of names, commonly paranoid states or paranoid psychosis, but the ICD-10 and DSM-IV category is delusional disorder. It is this second group that has caused persistent difficulties in several respects; for example, regarding its terminology, relationship to schizophrenia, and forensic implications.
This chapter begins with definitions of the common paranoid symptoms, expanding upon their descriptions in Chapter 1, and then reviews the causes of such symptoms. Next comes a short account of paranoid personality. This is followed by discussion of primary psychiatric disorders with which paranoid symptoms are
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frequently associated, and the differentiation of these disorders from delusional disorders. The general features of delusional disorder, and its major subtypes are then reviewed. A historical perspective is also given, with particular reference to paranoia and paraphrenia. The chapter finishes with a summary of the assessment and treatment of patients with paranoid symptoms.
It was pointed out above that the commonest paranoid delusions are persecutory. The term paranoid is also applied to the less common delusions of grandeur and jealousy, and sometimes to delusions concerning love, litigation, or religion. It may seem puzzling that such varied delusions should be grouped together. The reason is that the central abnormality implied by the term paranoid is a morbid distortion of beliefs or attitudes concerning relationships between oneself and other people. If someone believes falsely or on inadequate grounds that he is being victimized, or exalted, or deceived, or loved by a famous person, then in each case he is construing the relationship between himself and other people in a morbidly distorted way.
The varieties of paranoid symptom were discussed in Chapter 1, but important ones are also outlined in Box 13.1 for convenience. The definitions are derived from the glossary to the Present State Examination (p. 63; Wing et al., 1974).
Causes of paranoid symptoms
When paranoid symptoms occur as part of another psychiatric disorder, the main aetiological factors are those determining the primary illness. However, the question still arises as to why some people develop paranoid symptoms, whilst others do not. It has usually been answered in terms of premorbid personality, and social isolation.
Many writers, including Kraepelin, have held that paranoid symptoms are most likely to occur in patients with premorbid personalities of a paranoid type (see next section). Kretschmer (1927) also believed this, and thought that such people developed sensitive delusions of reference (sensitive Beziehungswahn) as an understandable psychological reaction to a precipitating event. Modern studies of so-called late-onset paraphrenia have supported these views (see Box 3.2). Thus Kay and Roth
BOX 13.1 SOME PARANOID SYMPTOMS
Ideas of reference Ideas of reference are held by people who are unduly self-conscious. The subject cannot help feeling that people take notice of him in buses, restaurants, or other public places, and that they observe things about him that he would prefer not to be seen. He realizes that this feeling originates within himself and that he is no more noticed than other people, but all the same he cannot help the feeling, quite out of proportion to any possible cause.
Delusions of reference Delusions of reference consist of an elaboration of ideas of reference, to the point that the beliefs become delusional. The whole neighbourhood may seem to be gossiping about the subject, far beyond the bounds of possibility, or she may see references to herself in the media. She may hear someone on the radio say something connected with a topic she has just been thinking about, or she may seem to be followed, her movements observed, and what she says taperecorded. The importance of distinguishing a delusion of reference from an idea of reference is that the former is a symptom of psychosis.
Delusions of persecution When a person has delusions of persecution he believes that a person, organization, or power, is trying to kill him, harm him in some way, or damage his reputation. The symptom may take many forms, ranging from the direct belief that he is being hunted down by specific people to vague, bizarre, or impossible plots.
Delusions of grandeur These may be divided into delusions of grandiose ability and delusions of grandiose identity. The subject with delusions of grandiose ability thinks that she is chosen by some power, or by destiny, for a special purpose because of her unusual talents. She may think that she is able to read people’s thoughts, is much cleverer than anyone else, or has invented machines or solved mathematical problems beyond most people’s comprehension.
The subject with delusions of grandiose identity believes that she is famous, rich, titled, or related to prominent people. She may believe that she is a changeling and that her real parents are royalty.
Page 309 PARANOID PERSONALITY DISORDER
(1961) found paranoid or hypersensitive personalities in over half of their group of 99 subjects with late-onset paraphrenia.
Freud (1911) proposed that, in predisposed people, paranoid symptoms could arise through the defence mechanisms of denial and projection. He held that a person does not consciously admit his own inadequacy and self-distrust, but projects them onto the outside world. Freud also held that paranoid symptoms could arise when denial and projection were being used as defences against unconscious homosexual tendencies. These ideas were derived from his study of Daniel Schreber, the presiding judge of the Dresden appeal court (Freud, 1911). Freud never met Schreber, but read the latter’s autobiographical account of his paranoid illness (now generally accepted to be paranoid schizophrenia), together with a report by Weber, the physician m charge. Freud thought that Schreber could not consciously admit his homosexuality, and so the idea ’I love him’ was dealt with by denial and changed by a reaction formation to ’I hate him’; this was further changed by projection into ’it is not I who hate him, but he who hates me’, and this in turn became transformed to ’I am persecuted by him’. Freud believed that all paranoid delusions could be represented as contradictions of the idea ’I (a man) love him (a man)’. He went so far as to argue that delusions of jealousy could be explained in terms of unconscious homosexuality; the jealous husband was unconsciously attracted to the man whom he accused his wife of loving. In this case the formulation was ’it is not I who love him; it is she who loves him’. At one time these ideas were widely taken up, but nowadays they gain little acceptance. They are not supported by clinical experience.
Social isolation and deafness
Social isolation may also predispose to the emergence of paranoid symptoms. Prisoners (especially those in solitary confinement), refugees, and migrants have all been considered to be prone to paranoid symptoms and syndromes, with social isolation being the common factor. The findings and their interpretation with regard to migration were discussed in Chapter 12 (p. 290).
There is evidence that deafness increases the risk of paranoid symptoms, as originally noted by Kraepehn, and usually attributed to the social isolation produced by deafness. Houston and Royse (1954) found an association between deafness and paranoid schizophrenia, whilst Kay and Roth (1961) found hearing impairment in 40 per cent of patients with late-onset paraphrenia.
Subsequent studies confirm that hearing impairment is a risk factor for disorders in which paranoid symptoms occur, and that this relationship is stronger in but not limited to the elderly (David et al, 1995; Prager and Jeste,
1993). However, it should be remembered that the great majority of deaf people do not become paranoid, and many deaf people may not be socially isolated.
Paranoid personality disorder
The concept of personality disorder was discussed in Chapter 7, and paranoid personality disorder was briefly described there. It is characterized by:
» extreme sensitivity to setbacks and rebuffs
» a tendency to misconstrue the actions of others as hostile or contemptuous
» a combative and inappropriate sense of personal rights.
This definition embraces a wide range of types. At one extreme is the excessively sensitive youth who shrinks from social encounters and thinks that everyone disapproves of him. At the other is the assertive and challenging woman who flares up at the least provocation. A recent American study found a 4.4 per cent prevalence of DSM-IV paranoid personality disorder, which is higher than previous estimates; the study also showed that the disorder had a significant impact on social and role functioning (Grant et al, 2004).
Because of the implications for treatment, it is important to distinguish paranoid personality disorder from the paranoid syndromes (delusional disorders) to be described later. The distinction can be very difficult to make, and is based on the fact that in paranoid personality disorder there are no delusions (only overvalued ideas), and no hallucinations. Separating paranoid ideas from delusions calls for considerable skill. The criteria for doing so were given in Chapter 1, and exemplified by the comparison made in Box 13.1 between ideas of reference and delusions of reference. In reality-. the conditions are likely on a continuum. Thus, family studies indicate a genetic relationship between paranoid personality disorder and delusional disorder (p. 313), whilst individuals with paranoid personality traits are at increased risk of developing a delusional disorder. It has been suggested that this may have happened to the philosopher, Jean Jacques Rousseau and the dictator, Joseph Stalin (Hachinski, 1999).
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Paranoid symptoms in psychiatric disorders
Paranoid symptoms are often secondary to an underlying or primary psychiatric disorder. Thus, when paranoid symptoms, especially persecutory delusions, are elicited it is important to assess for the other features of these disorders. The diagnosis of delusional disorder, to be considered below, is in many respects a ’residual’ category, used for patients whose delusions cannot be attributed to one of these other conditions. As the primary disorders are described at length in other chapters, they are mentioned only briefly here.
Paranoid symptoms in delirium and dementia
Paranoid symptoms are common in delirium. Impaired grasp of what is going on around the patient may give rise to apprehension and misinterpretation, and so to suspicion. Delusions may then emerge which are usually transient and disorganized; they may lead to disturbed behaviour, such as querulousness or aggression. Similarly, persecutory delusions occur commonly at some stage in dementia, and are occasionally the presenting feature Organic causes of paranoid symptoms and states were reviewed by Gorman and Cummings (1990).
Paranoid symptoms in substance misuse disorders
Paranoid symptoms occur in many substance misuse disorders, especially those associated with amphetamines, cocaine and alcohol. An important example is the association between alcohol misuse and morbid jealousy, described below. Some therapeutic drugs can also precipitate paranoid symptoms, such as L-DOPA (Gorman and Cummings, 1990).
Paranoid symptoms in mood disorders
Paranoid symptoms are not uncommon in patients with severe depressive disorders, and paranoid delusions are a feature of psychotic depression.
It is sometimes difficult to determine whether the paranoid symptoms are secondary to depressive disorder, or vice versa. Both scenarios are common. The distinction is of some importance as the two disorders differ in treatment and prognosis. A depressive disorder is likely if the mood changes occurred earlier and are of greater intensity than the paranoid features. Previous psychiatric history and family history may also be useful pointers. Finally, in depressive disorder, the patient typically accepts the persecution as justified by his own guilt or wickedness. This is a useful point clinically, since it contrasts with non-affective psychoses, wherein such persecutions are resented bitterly.
Paranoid symptoms also occur in mania, and are typically mood-congruent and thus grandiose rather than persecutory.
Paranoid symptoms and paranoid schizophrenia
Paranoid schizophrenia was described in Chapter 12 Its distinction from delusional disorders has been particularly problematic, both conceptually and practically (see Box 13.2), but the difficulties can be decreased by noting the differences in their core features (compare Table 12.6 with Table 13.1). Three features help in making the distinction in cases of doubt:
» The diagnosis of paranoid schizophrenia rather than delusional disorder is suggested if the paranoid delusions are particularly odd in content (often referred to by psychiatrists as bizarre delusions). Except in extreme cases, judgment as to how bizarre they are must be arbitrary (Flaum et al, 1991). DSM-IV defines non-bizarre delusions as involving situations that could conceivably occur in real life, for example, being followed, poisoned, or loved at a distance. ICD-
10, perhaps recognizing the difficulty of defining bizarre, omits this criterion.
* In schizophrenia, delusions tend to be fragmented and multiple, whereas in delusional disorder they are systematized and based around a single, internally consistent, theme. In delusional disorder, the delusional system is also characteristically encapsulated, such that the rest of the mental state can appear remarkably normal, in contrast to schizophrenia.
* Patients with paranoid schizophrenia often have auditory hallucinations, and the content of these seems unrelated to their delusions. In delusional disorder, hallucinations are rare, and when they do occur are fleeting and clearly related to the delusions
Paranoid symptoms in schizophrenia-like syndromes
Paranoid symptoms are features of several schizophrenia-like syndromes discussed in Chapter 12 (and listed in Table 12.5). These include the DSM-IV categories of ’brief psychotic disorders’ and ’schizophreniform disorder’, and the ICD-10 categories grouped under the heading ’acute and transient psychotic disorders’.
Delusional disorders (paranoid psychoses)
As mentioned in the introduction, the terminology and classification of psychoses which are neither affective, organic, nor schizophrenia, has been disputed for many years. Box 13.2 summarizes the main historical terms and themes, and provides the backdrop to the way in which the disorders are currently categorized. In this section, the core features of delusional disorders- the current terminology for these conditions – are described. The specific types of delusional disorder are covered in the following section.
Page 311 DELUSIONAL DISORDERS (PARANOID PSYCHOSES)
BOX 13.2 HISTORICAL BACKGROUND: PARANOIA AND PARAPHRENIA
The terms paranoia and paraphrenia have played a prominent part in psychiatric thought. Much can be learned from reviewing the conceptual difficulties associated with them
The term paranoia, from which the modern adjective paranoid is derived, has a long and chequered history. It has probably given rise to more controversy and confusion of thought than any other term used in psychiatry. A comprehensive review of the large body of literature, which is mostly German, and from the period before the 1970s has been provided by Lewis (1970); see also Box 1.2. The word is derived from the Greek para (beside) and nous (mind). It was used in ancient Greek literature to mean ’out of mind’, i.e. of unsound mind or insane. This broad usage was revived in the eighteenth century, but when it came into prominence in the second half of the nineteenth century, in German psychiatry, it became particularly associated with conditions characterized by delusions of persecution and grandeur. The German term Verrudctheit was often applied to these conditions, but eventually was superseded by paranoia. There were many different conceptions of these disorders. The main issues, most of which remain today, can be summarized as follows:
• Did these conditions constitute a primary disorder, or were they secondary to another disorder?
• Did they persist unchanged for many years, or were they a stage in an illness which later manifested deterioration of intellect and personality?
• Could they occur in the absence of hallucinations?
, Were there forms with good prognosis?
Kahlbaum raised these issues as early as 1863, when he classified paranoia as an independent primary condition which would remain unchanged over the years. Kraepelin had a strong influence on the conceptual history of paranoia, although he was never comfortable with the term, and his views changed strikingly over the years. In 1896 he used the term only for incurable, chronic, and systematized delusions without severe personality disorder. In the sixth edition of his textbook he wrote:
’The delusions in dementia praecox [schizophrenia] are extremely fantastic, changing beyond all reason, with an absence of system and a failure to harmonize them with events of their past life; while in paranoia the delusions are largely confined to morbid interpretations of real events, are woven together into a coherent whole, gradually becoming extended to include even events of recent date, and contradictions and objects are apprehended and explained’.
(Kraepelin 1904, p. 199)
In later descriptions, Kraepelin (1919) used the distinction made by Jaspers (1913) between personality development and disease process. He proposed paranoia as an example of the former, in contrast to the disease process of dementia praecox. In his final account, Kraepelin (1919) developed these ideas by distinguishing between dementia praecox, paranoia, and a third paranoid psychosis, paraphrenia. He suggested that:
» Dementia praecox had an early onset and a poor outcome ending in mental deterioration, and was fundamentally a disturbance of affect and volition.
• Paranoia was restricted to patients with the late onset of completely systematized delusions and a prolonged course, usually without recovery but not inevitably deteriorating. An important point was that the patients did not have hallucinations.
• Paraphrenia was somewhat intermediary, in that the patient had unremitting systematized delusions but did not progress to dementia. The main difference from paranoia was that the patient with paraphrenia had hallucinations.
Bleuler’s concept of the paranoid form of dementia praecox (which he later called paranoid schizophrenia) was broader than that of Kraepelin (Bleuler 1906,1911). Thus Bleuler did not regard paraphrenia as a separate condition, but as part of dementia praecox. However, he accepted Kraepelin’s view of paranoia as a separate entity, although he differed from Kraepelin in maintaining that hallucinations could occur in many cases. Bleuler was particularly interested in the psychological development of paranoia; at the same time he left open the question of whether paranoia had a somatic pathology.
From this time, two views of paranoia predominated. The first theme was that paranoia was distinct from schizophrenia and psychogenic in origin. The second theme was that paranoia was part of schizophrenia. Some celebrated studies of individual cases appeared to support the first theme. For example, Gaupp (1974) made an intensive study of the diaries
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[BOX 13.2 (continued)
and mental state of the mass murderer Wagner who murdered his wife, four children, and eight other people as part of a careful plan to revenge himself on his supposed enemies. Gaupp concluded that Wagner suffered from paranoia in the sense described by Kraepelin. At the same time, he believed that Wagner’s first recognizable delusions developed as a psychogenic reaction. The most detailed argument for psychogenesis was put forward by Kretschmer (1927) in his monograph ’Der Sensitive Beziehungswahn’. Kretschmer believed that paranoia should not be regarded as a disease, but as a psychogenic reaction occurring in people with particularly sensitive personalities. However, many of Kretschmer’s cases would nowadays be classified as schizophrenia. In
1931, Kolle put forward evidence for the second view, that paranoia is part of schizophrenia. He analysed a series of 66 patients with so-called paranoia, including those diagnosed by Kraepelin. For several reasons, including symptomatic and genetic factors, Kolle came to the conclusion that paranoia was really a mild form of schizophrenia.
Considerably less has been written about paraphrenia. However, it is interesting that Mayer (1921), following up Kraepelin’s series of 78 paraphrenic patients, found that 50 of them had developed schizophrenia. He found no difference in original clinical presentation between those who developed schizophrenia and those who did not. Since then paraphrema has increasingly been regarded as late-onset schizophrenia or schizophrenia-like disorder of good prognosis. Kay and Roth (1961) used the term late paraphrenia to denote paranoid conditions in the elderly that were not due to primary organic or affective illnesses. These authors found that a large majority of their 99 patients had the characteristic features of schizophrenia.
In current classifications, the term paranoia has, in effect, been replaced by delusional disorder. Paraphrenia does not feature either, but it continues to be used clinically to describe chronic, atypical, paranoid psychoses of middle and late life (see p. 513).
Classification of delusional disorder
TABLE 13.1 DSM-IV criteria for delusional disorder
A Non-bizarre delusions (le involving situations tha: occur in real life, such as being followed, poisoned, infected, loved at a distance or deceived by spouse or lover, or having a disease) of at least
1 month’s duration
B Criterion A for schizophrenia has never been met
Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme
C Apart from the impact of the delusion(s) or its ramifications functioning is not markedly impaired and behaviour is not obviously odd or bizarre
D If mood episodes have occurred concurrently with delusions their total duration has been brief relative to the duration of the delusional periods
E The disturbance is not due to the direct physiological effects of a substance (eg a drug of abuse, a medication) or a general medical condition
SPECIFIC DELUSIONAL DISORDERS 313
DSM-IV, the symptoms must have been present for at least 3 months, and the delusions are not required to be
’non-bizarre.’ ICD-10 also includes litigious and self-ref-erential subtypes, and has a separate sub-category
(F22.8) of ’other persistent delusional disorders’ (see below).
For reviews of delusional disorder, see Sedler (1995) and Munro (2000).
Epidemiology of delusional disorderDelusional disorder is regarded as being an uncommon illness, although there are relatively few data. In a cornmunity survey of over 5000 people aged 65 and over, Copeland et al. (1998) found a prevalence of 0.04 per cent for delusional disorder. In a retrospective study of over 10,000 outpatients, Hsiao et al. (1999) diagnosed 86 (0.83 per cent) as meeting DSM-IV criteria for delusional disorder of various kinds (Table 13.2). The disorder was a little more common in women than men and the mean age of onset of symptoms was 42 years. About 5 per cent of psychiatric inpatients with a diagnosis of functional psychosis met criteria for delusional disorder (Kendler and Walsh, 1995).
Significant depressive symptoms are common in delusional disorder (note category D in Table 13.1), being present in about a third of subjects (Hsaio et al,
1999; Serretti et al, 2004).
Aetiology of delusional disorder
What little is known of the aetiology of delusional disorder is based upon its relationship to, and comparison with, schizophrenia and paranoid personality disorder. This question has been addressed by family and neurobiological studies. However, the relatively small sample sizes and varying diagnostic definitions mean that few conclusions can be drawn. Psychological explanations for delusional disorder centre upon the delusions themselves, and are mentioned elsewhere (pp. 308-9).
TABLE 13.2 Subtypes of delusional disorder in 86 Chinese outpatients
Family studies of delusional disorder
First-degree relatives of patients with delusional disorder have an increased incidence of paranoid personality disorder (Kendler et al, 1985). The familial relationship of delusional disorder to schizophrenia is less clear. At present it appears that the risk of delusional disorder is increased in first-degree relatives of patients with schizophrenia, but relatives of patients with delusional disorder do not have an increased risk of schizophrenia or schizotypal personality (Kendler et al, 1995; Kendler and Walsh, 1995; Tienari et al, 2003). This familial association pattern has been called asymmetric co-aggregation and may be due to a number of factors:
» Differences in the incidence rates of the two disorders in the general population.
» Differences in diagnostic error rate between probands and relatives (probands are usually subject to more intensive assessment).
» A higher genetic loading for severe illness in those who come to medical attention (and are therefore assessed as probands).
Overall, there appears to be a weak genetic link between delusional disorder and, on the one hand, schizophrenia and, on the other, paranoid personality disorder. However, the extent of genetic overlap between these conditions is unclear. Most authorities would include delusional disorder as part of the schizophrenia spectrum (Kendler, 2003).
There is a familial association between alcoholism and delusional disorder (Kendler and Walsh, 1995), which could explain the association between morbid jealousy and alcohol misuse (see below).
Structural MRI studies suggest that elderly patients with delusional disorder have enlarged cerebral ventricles similar to patients with schizophrenia (Howard et al,
1995). The two groups may also show similar abnormalities in tasks of eye tracking (Campana et al, 1998). There are inconsistent and inconclusive reports that delusional disorder may be associated with polymorphisms in dopaminergic genes (e.g Morimoto et al, 2002).
Specific delusional disorders
As noted above, specific subtypes of delusional disorder are recognized, based on the content of the predominant delusion(s) (Table 13.3). Historically, these symptoms have been of particular interest to French psychiatrists.
page 314 13 PARANOID SYMPTOMS AND DELUSIONAL DISORDERS
» Some of the disorders are often referred to by older, eponymous terms.
* Some of the syndromes can be viewed as symptoms (e.g. delusional misidentification), or can occur secondary to other psychiatric disorders.
» Not all of the categories are included in DSM-IV or ICD-10, but are mentioned here because of continuing usage.
In this section we also consider stalking and persistent litigants, since both behaviours may be secondary to delusional disorder.
in this area is confusing for several reasons:Pathological jealousy
Pathological or morbid jealousy (other synonyms are given in Table 13.3) is described first and in most detail as it is the archetypal delusional disorder; it is also the commonest (other than ’persecutory delusional disorder, not otherwise specified’) and, importantly, appears to carry the greatest risk of dangerousness.
The essential feature is an abnormal belief that the patient’s partner is being unfaithful. The condition is called pathological because the belief, which may be a delusion or an overvalued idea, is held on inadequate grounds and is unaffected by rational argument. The belief is often accompanied by strong emotions and characteristic behaviour, but these do not in themselves constitute pathological jealousy. A man who finds his wife in bed with a lover may experience extreme jealousy and may behave in an uncontrolled way, but this should not be called pathological jealousy The term should be used only when the jealousy is based on unsound evidence and reasoning.
The main sources of information about pathological jealousy come from the classic paper by Shepherd (1961) and surveys by Langfeldt (1961), Vaukhonen (1968), and Mullen and Maack (1985). Shepherd examined the hospital case notes of 81 patients in London and Langfeldt did the same for 66 patients in Norway Vaukhonen made an interview study of 55 patients in Finland; Mullen and Mack examined the hospital case notes of 138 patients.
The frequency of pathological jealousy in the general population is unknown, although jealous feelings are ubiquitous (Mullen and Martin, 1994). Pathological jealousy is not uncommon in psychiatric practice, and most full-time clinicians probably see one or two cases a year. They merit careful attention, not only because of the great distress that they cause within marriages and families, but also because they may be highly dangerous.
It is likely that pathological jealousy is more common in men than in women. For example, the surveys noted above found that about two men are affected for every woman. However, the precise sex ratio may depend on the particular group studied and in particular whether the jealousy is secondary to another disorder. For example, in a retrospective survey of in-patients, Soyka et al (1991) found that amongst patients with paranoid schizophrenia more females than males had delusions of jealousy, whilst amongst patients with alcoholic psychosis more men developed delusional jealousy (even allowing for the fact that more men than women were affected with alcoholic psychosis).
TABLE 13.3 Types of delusional disorder
Type Synonymous with, or includes
Jealous Morbid jealousy, pathological jealousy, erotic jealousy, sexual jealousy, Othello syndrome
Erotic Erotomania; De Clerambault’s syndrome
Somatic Monosymptomatic hypochondnacal psychosis; delusional body dysmorphic disorder
Shared Induced delusional disorder, folie a deux, communicated insanity
Other Delusional misidentification syndrome, Capgras syndrome, Fregoli delusion, intermetamorphosis, syndrome of subjective doubles
Clinical features of pathological jealousy
Page 315 SPECIFIC DELUSIONAL DISORDERS
partner becomes exasperated and worn out, and is finally goaded into making a false confession. If this happens, the jealousy is inflamed rather than assuaged.
An interesting feature is that the jealous person often has no idea as to who the supposed lover may be, or what kind of person he or she may be. Moreover, he may avoid taking steps that could produce unequivocal proof one way or the other.
Behaviour may be strikingly abnormal. A successful city businessman carried a briefcase that contained not only his financial documents but also a machete for use against any lover who might be detected. A carpenter installed an elaborate system of mirrors in his house so that he could watch his wife from another room. A third patient avoided waiting alongside another car at traffic lights, in case his wife in the passenger seat might surreptitiously make an assignation with the other driver.
Aetiology of pathological jealousy
Pathological jealousy – as with other paranoid symptoms and syndromes – is associated with a range of primary disorders (Table 13.4). In the surveys mentioned, the frequencies of disorders varied, probably reflecting the population studied and the diagnostic scheme used. For example, paranoid schizophrenia was reported in
17-44 per cent of patients, depressive disorder in 3-16 per cent, neurosis and personality disorder in 38-57 per cent, alcoholism in 5-7 per cent, and organic disorders in 6-20 per cent.
The role of personality in the genesis of pathological jealousy should be stressed. It is often found that the patient has a pervasive sense of inadequacy, together with low self-esteem. There is a discrepancy between his ambitions and his attainments. Such a personality is particularly vulnerable to anything that may heighten this sense of inadequacy, such as loss of status or advancing age. In the face of such threats the person may project the blame onto others, and this may take the form of jealous accusations of infidelity. As mentioned earlier, Freud believed that unconscious homo-
TABLE 13.4 Disorders associated with pathological
Substance misuse (especially alcohol)
Paranoid personality disorder
sexual urges played a part in all jealousy, but clinical studies do not support an association between homosexuality and pathological jealousy. Similarly, though pathological jealousy has sometimes been attributed to the onset of sexual difficulties, Langfeldt (1961) and Shepherd (1961) found little or no evidence of an association.
Prognosis of pathological jealousy
Little is known about the prognosis of pathological jealousy. It likely depends on a number of factors, including the nature of any underlying psychiatric disorder and the patient’s premorbid personality. When Langfeldt (1961) followed up 27 of his patients after 17 years, he found that over half of them still had persistent or recurrent jealousy. This confirms a general clinical impression that the prognosis is often poor.
Risk of violence
Although there are no good estimates of the risks of violence, there is no doubt that people with pathological jealousy can be dangerous (Silva et al, 1998). Three out of 81 patients in Shepherd’s (1961) series had shown homicidal tendencies. In addition to homicide, the risk of physical injury inflicted by jealous patients is considerable. In Mullen and Maack’s (1985) series, a quarter had threatened to kill or injure their partner, and 56 per cent of men and 43 per cent of women had been violent to or threatened the supposed rival. Recently, Schanda et al. (2004), studying convicted murderers in Austria, confirmed that delusional disorder (subtype not specified) is associated with homicide, with an odds ratio of 6. There is also a risk of suicide, particularly when an accused partner finally decides to end the relationship.
Assessment of pathological jealousy
The assessment of a patient with pathological jealousy should be particularly thorough, and should always include the partner, who should be interviewed separately whenever possible.
The partner may give a much more detailed account of the patient’s morbid beliefs and actions than can be elicited from the patient. The doctor should try to find out tactfully how firmly the patient believes in the partner’s infidelity, how much resentment he feels, and whether he has contemplated any vengeful action. What factors provoke outbursts of accusations and questioning? How does the partner respond to such outbursts? How does the patient respond in turn to the partner’s behaviour? Has there been any violence so far? Has there been any serious injury?
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In addition to these enquiries, the doctor should take a detailed marital and sexual history from both partners, and assess for underlying psychiatric disorder, as this will have implications for treatment.
Treatment of pathological jealousy
The treatment of pathological jealousy, as with other delusional disorders, is in principle fairly straightforward
– the mainstay being antipsychotic drugs – but in practice can be very difficult because of lack of insight and reluctance to collaborate in the treatment plan.
Adequate treatment of any associated disorder such as schizophrenia or a mood disorder is a first requisite. If alcohol or other substance misuse is present, specific treatment will be needed. In other cases the pathological jealousy may be the symptom of a delusional disorder, or an overvalued idea in a patient with low self-esteem and personality difficulties.
When the jealousy seems to be delusional in nature, a careful trial of an antipsychotic drug is worthwhile, though results are often disappointing. When the jealousy is an overvalued idea, treatment with selective serotonin re-uptake inhibitors (SSRIs) may be useful (Stein et al, 1994); however, no randomized trials have yet been reported. As noted above, even when depressive disorder is not the primary diagnosis, it frequently complicates pathological jealousy and may worsen it. Treatment with an antidepressant may help in these circumstances.
Psychotherapy may be given to patients where the jealousy appears to arise from personality problems. One aim is to reduce tensions by allowing the patient (and partner) to ventilate feelings. Behavioural methods include encouraging the partner to produce behaviour that reduces jealousy, for example, by refusal to argue, depending on the individual case. A study of cognitive therapy, in which patients were encouraged to identify faulty assumptions and taught strategies of emotional control, gave superior results relative to a waiting list control group (Dolan and Bishay, 1996).
If there is no response to outpatient treatment or if the risk of violence is high, inpatient care may be necessary. Not uncommonly, however, the patient appears to improve as an inpatient, only to relapse on discharge.
If there appears to be a risk of violence, the doctor should warn the partner even if this involves a breach of confidentiality (see Chapter 4). In some cases the safest procedure is to advise separation. It is not uncommon for feelings of pathological jealousy to wane once a relationship has ended. Sometimes, however, the problem re-emerges if the patient enters a new relationship.
Erotomania and erotic delusions
Erotic delusions can occur in any psychotic disorder, especially paranoid schizophrenia, but they are the predominant and persistent symptom in a form of delusional disorder called erotomania. It was a French psychiatrist, De Clerambault who, in 1921, proposed that a distinction should be made between paranoid delusions and delusions of passion. The latter differed in their pathogenesis and in being accompanied by excitement. This distinction is of historical interest only, but the syndrome is still known as De Cle”rambault’s syndrome. It is rare and occurs almost entirely in women, although Taylor et al. (1983) reported four cases in a series of 112 men charged with violent offences.
In erotomania, the subject, usually a single woman, believes that an exalted person is in love with her. The supposed lover is usually inaccessible, as he is already married, or famous as an entertainer or public figure. According to De Clerambault, the infatuated woman believes that it is the supposed lover who first fell in love with her, and that he is more in love than she. She derives satisfaction and pride from this belief. She is convinced that the supposed lover cannot be a happy or complete person without her.
The patient often believes that the supposed lover is unable to reveal his love for various unexplained reasons, and that he has difficulties in approaching her, has indirect conversations with her, and has to behave in a paradoxical and contradictory way. The woman may be a considerable nuisance to the supposed lover, who may complain to the police and the courts Sometimes the patient’s delusion remains unshakeable, and she invents explanations for the other person’s paradoxical behaviour. She may be extremely tenacious and impervious to reality. Other patients turn from a delusion of love to a delusion of persecution, become abusive, and make public complaints about the supposed lover. This was described by De Clerambault as two phases – hope followed by resentment.
The concept of erotomania has been reviewed by Berrios and Kennedy (2002).
A proportion of ’stalkers’ appear to suffer from delusional disorders, including erotomania, which is why the topic is mentioned here.
There is no clear consensus about the definition of stalking. Most formulations contain the following elements:
» A pattern of intrusive behaviour.
» The intrusive behaviour is associated with implicit or explicit threats.
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» The person being stalked experiences fear and distress.
Stalkers typically follow their victim around and loiter outside their house or place of work. Unwanted communications by telephone, letter, graffiti, and, more recently, e-mail, are very common. Behaviour can then become more threatening with hoax advertisements or orders for services, scandalous rumour-mongering, damage to the victim’s property, threats of violence, and actual assault.
Stalkers are a heterogenous group with differing underlying psychopathologies. Some, usually women, have erotomania or erotic delusions secondary to other psychotic disorders. Patients with pathological jealousy can also stalk their victims (Silva et al, 2000). More cornmonly, stalkers suffer from personality disorder, predominantly with borderline, narcissistic, and sociopathic traits. They have often had a relationship with their victim that may have been quite superficial; in other cases, however, a serious relationship has cooled. A previous history of domestic violence in the relationship puts the victim at particularly high risk of assault and injury. Whether or not victims suffer actual assault, they invariably experience severe psychological stress, which can lead to anxiety and mood disorders and posttraumatic stress disorder. (For a review of stalking see Kamphuis and Emmelkamp, 2000 or Mullen etal, 2000; see also Chapter 26.)
Somatic delusional disorder
People with somatic delusional disorder believe that they suffer from a physical illness or deformity. The term encompasses monosymptomatic hypochondriacal psychosis, where there is a single delusional belief of this kind. Somatic delusional disorder needs to be distinguished from the hypochondriacal delusions that occur in severe depression and schizophrenia. It must also be distinguished from patients with severe body dysmorphic disorder (also called dysmorphophobia; see p. 209), in whom the overvalued ideas can approach delusional intensity. In fact, there appears to be much overlap clinically, and perhaps therapeutically, between delusional and non-delusional forms of body dysmorphic disorder (Phillips, 2004). Specific drug treatments for somatic delusional disorder have been advocated, as discussed below.
Querulant delusions and reformist delusions
Querulant delusions were the subject of a special study by Krafft-Ebing (1888). Patients with this kind of delusion indulge in a series of complaints and claims lodged
against the authorities. Closely related to querulant patients are paranoid litigants, who undertake a succession of lawsuits; they become involved in numerous court hearings, in which they may become passionately angry and may make threats against the magistrates. The characteristics of persistent litigants have been reviewed by Rowlands (1988) and Lester et al. (2004).
Baruk (1959) described ’reformist delusions’, which are centred on religious, philosophical, or political themes. People with these delusions constantly criticize society and sometimes embark on elaborate courses of action. Their behaviour may be violent, particularly when the delusions are political. Some political assassins fall within this group. It is extremely important that this diagnosis is made on clear psychiatric grounds rather than political grounds, as occurred in the Soviet Union (see Chapter 2; Bloch and Chodoff, 1981).
Delusional misidentification syndrome
Another group of delusions involve different aspects of misidentification, either of the self or others. They often occur in other psychotic disorders, especially schizophrenia and organic disorders, but they can also occur in isolation, and have been given the collective label of delusional misidentification syndrome (Ellis and Young, 1990; Christodoulou, 1991). This category is not named in ICD-10 or DSM-IV, but constitutes an example of ’other persistent delusional disorders’ coded in the former. One argument for bringing them together is that they all appear to be ’face processing disorders’, and associated with abnormalities in the posterior part of the right hemisphere wherein systems subserving face recognition are located (Cutting,
1991; Breen et al, 2000). Note also the seemingly close relationship of these disorders to the neurological category of prosopagnosia, the inability to recognize familiar faces. Interestingly, the delusions are specific to a few, usually familiar, people, and recognition of other faces (and objects) is not impaired. Although the beliefs are delusional, the patient is aware that something is wrong with the ’replacement’ person. The patient may be extremely distressed, and occasionally act against persons they believe to be impostors.
As outlined here, four main variants of delusional misidentification are recognized. In each case, there has been debate as to whether they constitute a symptorn or a syndrome.
Although there had been previous case reports, the condition now known as Capgras syndrome was well described by Capgras and Reboul-Lachauz in 1923. They
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called it I’tllusion des sosies (illusion of doubles), but it is a delusion not an illusion, hence the alternative term of Capgras delusion.
The patient believes that a person closely related to her has been replaced by a double. She accepts that the misidentified person has a great resemblance to the familiar person, but still believes that they are different people. It is a rare condition, seen more often in women than men. A history of depersonalization, derealization, or deja vu is not unusual. Schizophrenia is the commonest diagnosis (Berson, 1983). The misidentified person is usually the patient’s partner or another relative. Some patients with Capgras syndrome may behave dangerously by attacking the presumed doubles. The syndrome is an example of a reduplicative paramnesia (Lishman, 1998). For review, see Edelstyn and Oyebode (1999).
Also called the Fregoli delusion, it derives its name from an actor called Fregoli who had remarkable skill in changing his facial appearance. It was originally described by Courbon and Fail in 1927. The condition is even rarer than the Capgras delusion. The patient believes that one or more people have changed their appearance to resemble familiar people, usually in order to persecute her. She maintains that, although there is no physical resemblance between the familiar person and the others, nevertheless they are psychologically identical. This symptom is usually associated with schizophrenia or with organic brain disease (Portwich and Barocka, 1998).
In this syndrome, the patient believes that a person (or persons) has been transformed, both physically and psychologically, into another person, or that people have exchanged identities with each other. As with the other forms of delusional misidentification, note that intermetamorphosis is not a hallucination; the abnormality is one of interpretation not misperception.
The syndrome of subjective doubles In the syndrome of subjective doubles, the patient has the delusion that another person has been physically transformed into his own self, like a Doppelganger.Shared (induced) delusional disorder
Sometimes a person in a close relationship with someone who already has an established delusional system develops similar ideas. The commonest term is a/olie d deux, although the ICD-10 category is shared delusional
disorder, and the DSM-IV term is induced delusional disorder. It has also been called communicated insanity. The frequency of induced psychosis is not known, but it is low. Sometimes more than two people are involved (folie a plusieurs), but this is exceedingly rare It has been speculated that some apocalyptic cults involve phenomena of this kind.
Over 90 per cent or more of reported cases are members of the same family. Usually there is a dominant partner with fixed delusions who appears to induce similar beliefs in a dependent or suggestible partner, sometimes after initial resistance. The beliefs in the recipient may or may not be truly delusional. Generally the two people have lived together for a long time in close intimacy, often in isolation from the outside world. Once established, the condition runs a chronic course.
It is usually necessary to advise separation of the affected people. This may lead to resolution of the quasi-delusional state in the recipient; the original patient should be treated in the usual fashion for delusional disorder. See Silveira and Seeman (1995) for review.
Assessment of paranoid symptoms
In the assessment of paranoid symptoms there are two stages: the recognition of the symptoms themselves, and the diagnosis of the underlying condition.
Sometimes it is obvious that the patient has persecutory ideas or delusions. At other times recognition of paranoid symptoms may be exceedingly difficult. The patient may be suspicious or angry. They may be very defensive, say little, or speak fluently about other topics whilst steering away from persecutory beliefs or denying them completely. Considerable skill may be needed to elicit the false beliefs. The psychiatrist should be tolerant and impartial, acting as a detached but interested listener who wants to understand the patient’s point of view. The interviewer should show compassion and ask how they can help, but without colluding in the delusions or giving promises that cannot be fulfilled. Tact is required to avoid any argument that may cause the patient to take offence. Despite skill and tact, experienced psychiatrists may interview a patient for a long time without detecting the morbid thoughts. When an apparently false belief is disclosed, considerable time and effort may be needed to determine whether or not it meets the criteria for a delusion rather than an overvalued idea or other form of belief. This is of crucial diagnostic significance, since the presence of a delusion is likely to be the symptom upon
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which a diagnosis of psychotic disorder is based, whereas non-delusional thoughts which may be similar in content are consistent with a personality disorder or a neurotic disorder (e.g. hypochondriasis) depending on the other features of the history and mental state examination.
If delusions are detected, the next step is to diagnose the underlying psychiatric disorder. This means looking for the diagnostic features of the disorders noted earlier in this chapter (p. 310), and described in detail in other chapters. It is important to determine whether the patient is likely to try to harm any alleged persecutor. This calls for close study of the patient’s personality and the characteristics of his delusions and any associated hallucinations. Hints or threats of homicide should be taken seriously, in the same way as for suicide. A full risk assessment is needed. The doctor should be prepared to ask tactfully about possible homicidal plans and preparations to enact them. In many ways the method of enquiry resembles the assessment of suicide risk: ’Have you ever thought of doing anything about if’ ’Have you made any plans?’ ’What might prompt you to do it?’
The assessment of dangerousness is discussed further in Chapter 26.
Treatment of paranoid symptoms
Management of paranoid symptoms and delusional disorder is frequently difficult. The patient may be suspicious and distrustful, believing that psychiatric treatment is intended to harm them. Or, regarding their delusional beliefs as justified, see no need for treatment. The same tact and skill needed to encourage them to describe their symptoms fully is also necessary to persuade them then to accept treatment. Sometimes treatment can be made acceptable by offering to help non-specific symptoms such as anxiety or insomnia, or by pointing out the harmful consequences of the beliefs. Thus a patient who believes that he is surrounded by persecutors may agree that his nerves are being strained as a result, and that this needs treatment.
A decision must be made whether to admit the patient for inpatient care. This may be indicated if there is a significant or immediate risk of violence to others, or of suicide. When assessing such factors, consult other informants and to obtain a history of the patient’s behaviour. If voluntary admission is refused, compulsory admission may be justified to protect the patient or other people, although this is likely to add to the patient’s resentment.
Patients with paranoid symptoms require support, encouragement, and reassurance. This form of nonspecific psychological treatment is an integral part of management, and essential if the patient is to be persuaded of the benefits of more targeted interventions. Of the latter, drugs are the mainstay of treatment (see below), but specific psychological therapies may have a role too. In particular, cognitive therapy, as used for the treatment of delusions in schizophrenia, may be worth trying if a sufficiently good therapeutic rapport exists. Interpretative psychotherapy and group psychotherapy are unsuitable.
Paranoid symptoms in delusional disorder are treated with antipsychotic drugs just as in other psychoses. The importance of establishing a good therapeutic relationship to improve collaboration with treatment has already been emphasized.
Antipsychotics for delusional disorder
Munro has advocated pimozide as the drug of choice, particularly for monosymptomatic hypochondriacal psychosis (delusional disorder, somatic type in DSM-IV) and pathological jealousy (Munro, 2000); however, there is no good randomized evidence that it is more effective than other antipsychotics (Sultana and McMonagle,
2000). Also, pimozide’s potential cardiotoxicity should be taken into account. Newer antipsychotics may be better tolerated. A non-sedating drug is usually preferable. Whichever is chosen, it is important to start with a low dose, and to take into account the patient’s age, coexistent medical conditions, and prior treatment response.
Antidepressants for delusional disorder
Some randomized controlled trial data suggest that SSRIs rather than antipsychotics should be used as first line for treatment of the delusional form of body dysmorphic disorder, with antipsychotic augmentation for those who do not respond (Phillips, 2004). The role of antidepressants in other delusional disorders remains unclear, although they are often used at some stage in treatment, reflecting the frequency of comorbid depressive symptoms, and their emergence during treatment. The risk of suicide should be monitored regularly.
Signs of improvement, notably a decrease in preoccupation with the delusion(s) and reduction in agitation, may be seen within a few days of starting medication. There are few long-term outcome data. Clinical impression
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suggests that the prognosis in delusional disorder is poor, although Munro (2000) claims that, in compliant patients, full recovery occurs in 50 per cent with substantial improvement in another 30 per cent. In some patients, medication can be reduced or stopped without ill effects, whilst in others – probably the majority – delusions recur rapidly on discontinuation, and treatment must be maintained for prolonged periods. This issue can be judged only by a careful clinical trial with regular monitoring of mental state, and it requires discussion with the patient as to the risks and benefits of long-term medication.
Enoch MD, Ball HN (2001) Uncommon psychiatric syndromes, 4th edn. London, Edward Arnold. (Fascinating
descriptions of many delusional disorders, and other uncommon and eponymous psychiatric syndromes)
Hirsch, SR and Shepherd, M (eds) (1974) Themes and vanatwns in European psychiatry. John Wright, Bristol. (See the following sections: E Stromgren, Psychogenic psychoses; R Gaupp, The scientific significance of the case of Ernst Wagner and The illness and death of the paranoid mass murderer schoolmaster Wagner a case history; E Kretschmer, The sensitive delusion of reference; H Baruk, Delusions of passion; H Ey,)
Lewis, A (1970) Paranoia and paranoid: a historical perspective. Psychological Medicine 1, 2-12. (A searching and scholarly review of the origin and development of the term paranoid and related concepts.)
Munro A (1999) Delusional disorder. Cambridge, Cambndge University Press.
As indicated above, the main feature is an abnormal belief in the partner’s infidelity. This may be accompanied by other abnormal beliefs, for example, that the partner is plotting against the patient, trying to poison him, taking away his sexual capacities, or infecting him with venereal disease. The mood of the pathologically jealous patient may vary with the underlying disorder, but often it is a mixture of misery, apprehension, irritability, and anger.
Typically, the behaviour involves an intensive search for evidence of the partner’s infidelity, for example, by looking through diaries and by examining bed linen and underwear for signs of sexual secretions. The patient may follow the partner about, or engage a private detective. The jealous person often cross-questions the partner incessantly. This may lead to violent quarrelling and paroxysms of rage in the patient. Sometimes the
DSM-IV uses delusional disorder to describe a disorder with persistent, non-bizarre delusions that is not due to any other disorder. It is synonymous with the widely used term paranoid psychosis, and includes the nonspecific term of paranoid states. ICD-10 has a similar category of persistent delusional disorders. The essence of the modern concept of delusional disorder is that of a stable delusional system developing insidiously in a person in middle or late life. The delusional system is encapsulated, and there is no impairment of other mental functions. The patient can often go on working, and his social life may be maintained fairly well.
The criteria for delusional disorder in DSM-IV are summarized in Table 13.1, with the subsequent description of five specific subtypes of delusional disorder and two other categories:
ICD-10 gives a similar definition for the principal category (F22.0) of persistent delusional disorders. Unlike